Background: The goal of Canada's Compassionate Care Benefit (CCB) is to enable familymembers and other loved ones who are employed to take a temporary secured leave to care for aterminally ill individual at end of life. Successful applicants of the CCB can receive up to 55% of theiraverage insured earnings, up to a maximum of CDN$435 per week, over a six week period toprovide care for a gravely ill family member at risk of death within a six month period, as evidencedby a medical certificate. The goal of this study is to evaluate the CCB from the perspective of familycaregivers providing care to individuals at end of life. There are three specific research objectives.Meeting these objectives will address our study purpose which is to make policy-relevantrecommendations informed by the needs of Canadian family caregivers and input from other keystakeholders who shape program uptake. Being the first study that will capture family caregivers'experiences and perceptions of the CCB and gather contextual data with front-line palliative carepractitioners, employers, and human resources personnel, we will be in a unique position toprovide policy solutions/recommendations that will address concerns raised by numerousindividuals and organizations.Methods: We will achieve the research goal and objectives through employing utilization-focusedevaluation as our methodology, in-depth interviews and focus groups as our techniques of datacollection, and constant comparative as our technique of data analysis. Three respondent groupswill participate: (1) family caregivers who are providing or who have provided end of life care viaphone interview; (2) front-line palliative care practitioners via phone interview; and (3) humanresources personnel and employers via focus group. Each of these three groups has a stake in thesuccessful administration of the CCB. A watching brief of policy documents, grey literature, mediareports, and other relevant items will also be managed throughout data collection.Discussion: We propose to conduct this study over a three year period beginning in October,2006 and ending in October, 2009.

Background: Medical tourism is understood as travel abroad with the intention of obtaining non-emergencymedical services. This practice is the subject of increasing interest, but little is known about its scope.Methods: A comprehensive scoping review of published academic articles, media sources, and grey literaturereports was performed to answer the question: what is known about the patient’s experience of medical tourism?The review was accomplished in three steps: (1) identifying the question and relevant literature; (2) selecting theliterature; (3) charting, collating, and summarizing the information. Overall themes were identified from this process.Results: 291 sources were identified for review from the databases searched, the majority of which were mediapieces (n = 176). A further 57 sources were included for review after hand searching reference lists. Of the 348sources that were gathered, 216 were ultimately included in this scoping review. Only a small minority of sourcesreported on empirical studies that involved the collection of primary data (n = 5). The four themes identified viathe review were: (1) decision-making (e.g., push and pull factors that operate to shape patients’ decisions); (2)motivations (e.g., procedure-, cost-, and travel-based factors motivating patients to seek care abroad); (3) risks (e.g.,health and travel risks); and (4) first-hand accounts (e.g., patients’ experiential accounts of having gone abroad formedical care). These themes represent the most discussed issues about the patient’s experience of medical tourismin the English-language academic, media, and grey literatures.Conclusions: This review demonstrates the need for additional research on numerous issues, including: (1)understanding how multiple information sources are consulted and evaluated by patients before deciding uponmedical tourism; (2) examining how patients understand the risks of care abroad; (3) gathering patients’prospective and retrospective accounts; and (4) the push and pull factors, as well as the motives of patients toparticipate in medical tourism. The findings from this scoping review and the knowledge gaps it uncovered alsodemonstrate that there is great potential for new contributions to our understanding of the patient’s experience ofmedical tourism.

Background: As the populations of many developed nations continue to age at rapid rates it is becomingincreasingly important to enhance palliative care service delivery in order to meet anticipated demand. Rural areasface a number of challenges in doing this, and thus dedicated attention must be given to determining how to bestenhance service delivery in ways that are sensitive to their particular needs. The purposes of this article are todetermine the vision for establishing secondary palliative care service hubs (SPCH) in rural communities throughundertaking a case study, and to ascertain the criteria that need to be considered when siting such hubs.Methods: A rural region of British Columbia, Canada was selected for primary data collection, which took placeover a five-month period in 2008. Formal and informal palliative care providers (n = 31) were interviewed. Apurposeful recruitment strategy was used to maximize occupational and practice diversity. Interviews wereconducted by phone using a semi-structured guide. Interviews were audio recorded and transcribed verbatim.Data were managed using NVivo8™ software and analyzed thematically, using investigator triangulation tostrengthen interpretation.Results: Four themes emerged from the dataset: (1) main SPCH features; (2) determining a location; (3) valueaddedoutcomes; and (4) key considerations. It was found that participants generally supported implementing aSPCH in the rural region of focus. Several consistent messages emerged, including that: (1) SPCHs must createopportunities for two-way information exchange between specialists and generalists and communities; (2) SPCHsshould diffuse information and ideas throughout the region, thus serving as a locus for education and a means ofenhancing training opportunities; and (3) hubs need not be physical sites in the community (e.g., an office in ahospice or hospital), but may be virtual or take other forms based upon local needs.Conclusion: Visioning innovation in the provision of palliative care service in rural communities can be enhancedby consultation with local providers. Interviews are a means of determining local concerns and priorities. Therewas widespread support for SPCH coupled with some uncertainty about means of implementation.

Background: Unattached patients do not have a regular primary care provider. Initiatives are being developed toincrease attachment rates across Canada. Most existing attention paid to patient unattachment has focused onquantifying the problem and health system costs. Our purpose is to qualitatively identify the implications ofchronically ill patients’ experiences of unattachment for health policy and planning to provide policy-relevantinsights for Canadian attachment initiatives.Methods: Three focus groups were conducted with marginalized chronically ill individuals residing in a mid-sized city inBritish Columbia who are unattached to a family doctor. We use the term marginalized as a descriptor to acknowledgethat by virtue of their low socio-economic status and lack of attachment the participants are marginalized in Canada’shealth care system Focus groups were structured as an open conversation organized around a series of probingquestions. They were digitally recorded and transcribed verbatim. Thematic analysis was employed.Results: Twenty-six individuals participated in the focus groups. The most common chronic illnesses reported were activedrug addiction or recovery (and their associated symptoms), depression, arthritis, and hepatitis C. Participants identifiedlife transitions as being the root cause for not having a family doctor. There was a strong sense that unsuccessfulattempts to get a family doctor reflected that they were undesirable patients. Participants wanted to experience having atrusting relationship with a regular family doctor as they believed it would encourage greater honesty and transparency.One of the main health concerns regarding lack of access to a regular family doctor is that participants lacked access topreventative care. Participants were also concerned about having a discontinuous medical record due to unattachment.Conclusions: Participants perceived that there are many benefits to be had by having attachment to a regular familydoctor and that experiencing unattachment challenged their health and access to health care. We encourage moreresearch to be done on the lived experience of unattachment in order to provide on-the-ground insights thatpolicy-makers require in order to develop responsive, patient-centred supports and programs.

Background: Central to establishing continuity of care is the development of a relationshipbetween doctor and patient/caregiver. Transfer of information between these parties facilitates thedevelopment of continuity in general; and specifically informational continuity of care. Weconducted a systematic review of published literature to gain a better understanding of the rolesthat different parties – specifically doctors, patients, family caregivers, and technology – play inestablishing and maintaining informational continuity of care within family practice.Methods: Relevant published articles were sought from five databases. Accepted articles werereviewed and appraised in a consistent way. Fifty-six articles were retained following title andabstract reviews. Of these, 28 were accepted for this review.Results: No articles focused explicitly on the roles involved in establishing or maintaininginformational continuity of care within family practice. Most informational continuity of careliterature focused on the transfer of information between settings and not at the first point ofcontact. Numerous roles were, however, were interpreted using the data extracted from reviewedarticles. Doctors are responsible for record keeping, knowing patients' histories, recallingaccumulated knowledge, and maintaining confidentiality. Patients are responsible for disclosingpersonal and health details, transferring information to other practitioners (including new familydoctors), and establishing trust. Both are responsible for developing a relationship of trust.Technology is an important tool of informational continuity of care through holding importantinformation, providing search functions, and providing a space for recorded information. There isa significant gap in our knowledge about the roles that family caregivers play.Conclusion: The number of roles identified and the interrelationships between them indicatesthat establishing and maintaining informational continuity of care within family practice is a complexand multifaceted process. This synthesis of roles provided serves as an important resource forcontinuity of care researchers in general, for the development of continuity of care qualityindicators, and for the practice of family medicine.

Background: Providing palliative care is a growing priority for health service administratorsworldwide as the populations of many nations continue to age rapidly. In many countries, palliativecare services are presently inadequate and this problem will be exacerbated in the coming years.The provision of palliative care, moreover, has been piecemeal in many jurisdictions and there islittle distinction made at present between levels of service provision. There is a pressing need todetermine which populations do not enjoy access to specialized palliative care services in particular.Methods: Catchments around existing specialized palliative care services in the Canadian provinceof British Columbia were calculated based on real road travel time. Census block face populationcounts were linked to postal codes associated with road segments in order to determine thepercentage of the total population more than one hour road travel time from specialized palliativecare.Results: Whilst 81% of the province's population resides within one hour from at least onespecialized palliative care service, spatial access varies greatly by regional health authority. Based onthe definition of specialized palliative care adopted for the study, the Northern Health Authorityhas, for instance, just two such service locations, and well over half of its population do not havereasonable spatial access to such care.Conclusion: Strategic location analysis methods must be developed and used to accurately locatefuture palliative services in order to provide spatial access to the greatest number of people, andto ensure that limited health resources are allocated wisely. Improved spatial access has thepotential to reduce travel-times for patients, for palliative care workers making home visits, and fortravelling practitioners. These methods are particularly useful for health service planners – andprovide a means to rationalize their decision-making. Moreover, they are extendable to a numberof health service allocation problems.

Background: Extensive public health gains have benefited high-income countries in recent decades, however, citizensof low and middle-income countries (LMIC) have largely not enjoyed the same advancements. This is in part due to thefact that public health data - the foundation for public health advances - are rarely collected in many LMIC. Injury dataare particularly scarce in many low-resource settings, despite the huge associated burden of morbidity and mortality.Advances in freely-accessible and easy-to-use information and communication (ICT) technology may provide theimpetus for increased public health data collection in settings with limited financial and personnel resources.Methods and Results: A pilot study was conducted at a hospital in Cape Town, South Africa to assess the utility andfeasibility of using free (non-licensed), and easy-to-use Social Web and GeoWeb tools for injury surveillance in lowresourcesettings. Data entry, geocoding, data exploration, and data visualization were successfully conducted usingthese technologies, including Google Spreadsheet, Mapalist, BatchGeocode, and Google Earth.Conclusion: This study examined the potential for Social Web and GeoWeb technologies to contribute to publichealth data collection and analysis in low-resource settings through an injury surveillance pilot study conducted inCape Town, South Africa. The success of this study illustrates the great potential for these technologies to be leveragedfor public health surveillance in resource-constrained environments, given their ease-of-use and low-cost, and thesharing and collaboration capabilities they afford. The possibilities and potential limitations of these technologies arediscussed in relation to the study, and to the field of public health in general.

Over the past several decades researchers have produced substantial evidence of asocial gradient in a variety of health outcomes, rising from systematic differences in income,education, employment conditions, and family dynamics within the population. Social gradients inhealth are measured using deprivation indices, which are typically constructed from aggregatedsocio-economic data taken from the national census – a technique which dates back at least untilthe early 1970's. The primary method of index construction over the last decade has been aPrincipal Component Analysis. Seldom are the indices constructed from survey-based data sourcesdue to the inherent difficulty in validating the subjectivity of the response scores. We argue thatthis very subjectivity can uncover spatial distributions of local health outcomes. Moreover,indication of neighbourhood socio-economic status may go underrepresented when weightedwithout expert opinion. In this paper we propose the use of geographic information science (GIS)for constructing the index. We employ a GIS-based Order Weighted Average (OWA) MulticriteriaAnalysis (MCA) as a technique to validate deprivation indices that are constructed using morequalitative data sources. Both OWA and traditional MCA are well known and used methodologiesin spatial analysis but have had little application in social epidemiology.

Results:

A survey of British Columbia's Medical Health Officers (MHOs) was used to populate theMCA-based index. Seven variables were selected and weighted based on the survey results. OWAvariable weights assign both local and global weights to the index variables using a sliding scale,producing a range of variable scenarios. The local weights also provide leverage for controlling thelevel of uncertainty in the MHO response scores. This is distinct from traditional deprivationindices in that the weighting is simultaneously dictated by the original respondent scores and thevalue of the variables in the dataset.

Conclusion:

OWA-based MCA is a sensitive instrument that permits incorporation of expertopinion in quantifying socio-economic gradients in health status. OWA applies both subjective andobjective weights to the index variables, thus providing a more rational means of incorporatingsurvey results into spatial analysis.

BACKGROUND:During a mass casualty incident, evacuation of patients to the appropriate health care facility is critical to survival. Despite this, no existing system provides the evidence required to make informed evacuation decisions from the scene of the incident. To mitigate this absence and enable more informed decision making, a web based spatial decision support system (SDSS) was developed. This system supports decision making by providing data regarding hospital proximity, capacity, and treatment specializations to decision makers at the scene of the incident.METHODS:This web-based SDSS utilizes pre-calculated driving times to estimate the actual driving time to each hospital within the inclusive trauma system of the large metropolitan region within which it is situated. In calculating and displaying its results, the model incorporates both road network and hospital data (e.g. capacity, treatment specialties, etc.), and produces results in a matter of seconds, as is required in a MCI situation. In addition, its application interface allows the user to map the incident location and assists in the execution of triage decisions.RESULTS:Upon running the model, driving time from the MCI location to the surrounding hospitals is quickly displayed alongside information regarding hospital capacity and capability, thereby assisting the user in the decision-making process.CONCLUSIONS:The use of SDSS in the prioritization of MCI evacuation decision making is potentially valuable in cases of mass casualty. The key to this model is the utilization of pre-calculated driving times from each hospital in the region to each point on the road network. The incorporation of real-time traffic and hospital capacity data would further improve this model.

Epidemiologic studies have linked exposure to traffic-generated air and noise pollution with a wide range of adverse health effects in children. Children spend a large portion of time at school, and both air pollution and noise are elevated in close proximity to roads, so school location may be an important determinant of exposure. No studies have yet examined the proximity of schools to major roads in Canadian cities.

METHODS:

Data on public elementary schools in Canada's 10 most populous cities were obtained from online databases. School addresses were geocoded and proximity to the nearest major road, defined using a standardized national road classification scheme, was calculated for each school. Based on measurements of nitrogen oxide concentrations, ultrafine particle counts, and noise levels in three Canadian cities we conservatively defined distances < 75 m from major roads as the zone of primary interest. Census data at the city and neighborhood levels were used to evaluate relationships between school proximity to major roads, urban density, and indicators of socioeconomic status.

RESULTS:

Addresses were obtained for 1,556 public elementary schools, 95% of which were successfully geocoded. Across all 10 cities, 16.3% of schools were located within 75 m of a major road, with wide variability between cities. Schools in neighborhoods with higher median income were less likely to be near major roads (OR per $20,000 increase: 0.81; 95% CI: 0.65, 1.00), while schools in densely populated neighborhoods were more frequently close to major roads (OR per 1,000 dwellings/km2: 1.07; 95% CI: 1.00, 1.16). Over 22% of schools in the lowest neighborhood income quintile were close to major roads, compared to 13% of schools in the highest income quintile.

CONCLUSIONS:

A substantial fraction of students at public elementary schools in Canada, particularly students attending schools in low income neighborhoods, may be exposed to elevated levels of air pollution and noise while at school. As a result, the locations of schools may negatively impact the healthy development and academic performance of a large number of Canadian children.